U.S. patent application number 12/777729 was filed with the patent office on 2011-04-21 for use of high-dose oxazaphosphorine drugs for treating immune disorders.
This patent application is currently assigned to The Johns Hopkins University. Invention is credited to Robert A. Brodsky, Richard J. Jones.
Application Number | 20110092462 12/777729 |
Document ID | / |
Family ID | 37898760 |
Filed Date | 2011-04-21 |
United States Patent
Application |
20110092462 |
Kind Code |
A1 |
Brodsky; Robert A. ; et
al. |
April 21, 2011 |
USE OF HIGH-DOSE OXAZAPHOSPHORINE DRUGS FOR TREATING IMMUNE
DISORDERS
Abstract
This disclosure relates, at least in part, to methods of
eliminating adverse immune reactions in a subject in need thereof
including those associated with autoimmune diseases, allergic
reactions and transplant rejection, including administration of a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug
to the subject.
Inventors: |
Brodsky; Robert A.;
(Brooklandville, MD) ; Jones; Richard J.;
(Baltimore, MD) |
Assignee: |
The Johns Hopkins
University
Baltimore
MD
|
Family ID: |
37898760 |
Appl. No.: |
12/777729 |
Filed: |
May 11, 2010 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
11566296 |
Dec 4, 2006 |
|
|
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12777729 |
|
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60742172 |
Dec 2, 2005 |
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Current U.S.
Class: |
514/90 |
Current CPC
Class: |
A61P 37/00 20180101;
Y02A 50/30 20180101; A61P 37/02 20180101; A61K 45/06 20130101; A61K
35/19 20130101; A61P 25/00 20180101; A61K 38/193 20130101; A61K
31/675 20130101; Y02A 50/401 20180101; A61K 31/66 20130101; A61P
21/04 20180101; A61K 31/675 20130101; A61K 2300/00 20130101; A61K
38/193 20130101; A61K 2300/00 20130101; A61K 35/19 20130101; A61K
2300/00 20130101 |
Class at
Publication: |
514/90 |
International
Class: |
A61K 31/675 20060101
A61K031/675; A61P 37/02 20060101 A61P037/02 |
Claims
1. A method for treating a subject having an immune disorder
excluding aplastic anemia, chronic inflammatory demyelinating
polyneuropathy, paraneoplastic pemphigus, pemphigus foliaceus,
pemphigus vulgaris, or systemic lupus erythematosus comprising
administering a lymphocytoxic non-myeloablative amount of a
oxazaphosphorine drug to the subject, such that the subject's
immune system reconstitutes without stem cell transplantation and
such that the disorder remains in remission without the
administration of additional immunomodulatory agents, and wherein
there is no relapse for at least 1 year.
2. A method for treating a subject having an immune disorder
comprising administering a lymphocytoxic non-myeloablative amount
of a oxazaphosphorine drug to the subject, such that the subject's
immune system reconstitutes without stem cell transplantation and
such that the disorder remains in remission without the
administration of additional immunomodulatory agents, and wherein
there is no relapse for at least 4 years.
3-56. (canceled)
Description
RELATED APPLICATIONS
[0001] This application is a Continuation Application which claims
the benefit of priority to U.S. application Ser. No. 11/566,296,
filed Dec. 4, 2006 which claims the benefit of priority to U.S.
Provisional Application No. 60/742,172, filed Dec. 2, 2005.
BACKGROUND
[0002] Autoimmune diseases afflict more than 8 million people in
the U.S alone. Autoimmunity usually occurs when the lymphocytes,
which are designed to defend the body against infections and
foreign agents, start attacking one or more of the body's tissues
or organs. Examples of autoimmune diseases include, but are not
limited to, systemic lupus erythematosus, rheumatoid arthritis,
severe aplastic anemia, multiple sclerosis, autoimmune hemolytic
anemia, autoimmune neurologic diseases, type I diabetes, Grave's
disease, Crohn's disease, myasthenia gravis, myositis, Raynaud's
phenomenon, autoimmune thrombocytopenia, chronic hepatitis and
antiphospholipid syndrome.
[0003] The conventional treatment for many autoimmune diseases
includes the systemic use of anti-inflammatory drugs and potent
immunomodulatory agents, such as, for example, steroids, and
inhibitors of inflammatory cytokines. However, despite their
profound effect on immune responses, these therapies are often
unable to induce clinically significant remissions in many
patients.
[0004] In more recent years, researchers have contemplated the use
of stem cells for the treatment of autoimmune diseases, in
particular, hematopoietic stem cell transplant therapy (HCST). The
rationale is to destroy the mature, long-lived and auto-reactive
immune cells and to transplant a new properly functioning immune
system into the patient with the hope of eliciting a remission of
the autoimmune disease. By it's nature, HSCT is a very risky
procedure and for the duration of the recovery phase, until the
immune system is reconstituted, transplant recipients undergo a
period of dramatically increased susceptibility to bacterial,
fungal and viral infections, making this a high-risk therapy.
Further, these patients often require extended or life-long
immunosuppressive therapy because of re-establishment of the
disease caused by the cells that are transplanted and in some
instances, onset of graft versus host disease.
[0005] High-dose cyclophosphamide (for example, 50
mg/kg/day.times.4 days) has also been used for the treatment of
certain autoimmune diseases such as, for example, severe aplastic
anemia. Severe aplastic anemia (SAA) is a life-threatening bone
marrow failure disorder. With supportive care alone, most SAA
patients die within a year of diagnosis. Three approaches have
generally been used for the treatment of SAA. These are: (1)
immunosuppressive therapy; (2) high-dose cyclophosphamide followed
by allogeneic bone marrow transplantation; and (3) high-dose
cyclophosphamide without bone marrow transplantation.
[0006] While low to intermediate doses of cyclophosphamide have
been used in an attempt to treat other autoimmune diseases, its use
is limited due to the various undesirable side effects. For
example, administration of oral daily cyclophosphamide is currently
one of the most effective, if not the most effective,
immunosuppressive therapy for pemphigus vulgaris. However, the
toxicity of cyclophosphamide has limited its use for patients with
severe disease who are not responsive to or unable to tolerate
nonalkylating agents.
[0007] It is unclear whether high-dose cyclophosphamide and similar
drugs can be used without any additional therapies for long periods
of time and/or whether they can be used for the treatment of all
autoimmune and related disorders.
SUMMARY
[0008] This disclosure relates, at least in part, to methods of
eliminating or substantially reducing adverse immune reactions or
immune disorders in a subject in need thereof including those
associated with autoimmune diseases, allergic reactions and
transplant rejection, including administration of a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug to the subject,
such that the subject's immune system reconstitutes without both
stem cell transplantation and administration of additional
immunomodulatory agents. In some embodiments, the oxazaphosphorine
drug is cyclophosphamide.
[0009] In some embodiments, a method of treating multiple sclerosis
in subject is provided herein which comprises: (a) identifying a
subject that failed to respond to conventional therapy; and (b)
administering a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug to the subject, thereby to treat multiple
sclerosis.
[0010] In some embodiments, a method of treating multiple sclerosis
comprises: (a) identifying a subject having at least two gadolinium
enhancing lesions; and (b) administering a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug to the subject,
thereby to treat multiple sclerosis.
[0011] A method of treating multiple sclerosis described herein is
such that the subject's immune system reconstitutes without stem
cell transplantation and without administration of additional
immunomodulatory agents. In some embodiments, the subject is human.
Methods described herein can also be used for treating aggressive
relapsing remitting multiple sclerosis.
[0012] In some embodiments, a method of treating multiple sclerosis
involves administration of the oxazaphosphorine drug,
cyclophosphamide.
[0013] In some embodiments, a method of treating an immune disorder
excluding severe aplastic anemia, chronic inflammatory
demyelinating polyneuropathy, paraneoplastic pemphigus, pemphigus
foliaceus, pemphigus vulgaris and/or systemic lupus erthyematosus,
includes administering to a subject in need thereof, a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine
drug, such that the subject's immune system reconstitutes without
stem cell transplantation and such that the disease remains in
remission without administration of additional immunomodulatory
agents, and where there is no relapse for at least 1 year. In
certain embodiments, a method of treating an immune disorder,
includes administering to a subject in need thereof, a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine
drug, such that the subject's immune system reconstitutes without
stem cell transplantation and such that the disease remains in
remission without administration of additional immunomodulatory
agents, and where there is no relapse for at least 4 years.
[0014] In some embodiments, treatment includes curing an immune
disorder other than severe aplastic anemia, chronic inflammatory
demyelinating polyneuropathy, paraneoplastic pemphigus, pemphigus
foliaceus, and/or pemphigus vulgaris.
[0015] In some embodiments, a method of treating an immune disorder
other than severe aplastic anemia further includes the step of
administering an effective amount of granulocyte colony stimulating
factor to the subject. In certain embodiments, a method of treating
an autoimmune disease other than aplastic anemia additionally
includes the step of administering an effective amount of at least
one antimicrobial agent to the subject. In certain embodiments, a
method of treating an autoimmune disease other than aplastic anemia
additionally includes the step of administering an effective dose
of platelets to the subject. A method of treating an autoimmune
disease, as described herein, may include any one, two or all three
of these additional steps.
[0016] In some embodiments, an effective amount of platelets are
administered to a subject for a duration of time necessary for the
platelet count to be at least 10,000 platelets/mm.sup.3 and an
effective amount of granulocyte colony stimulating factor is
administered for a duration of time necessary for the neutrophil
count to be at least 500/mm.sup.3. In some embodiments, an
effective amount of red blood cells are administered to a subject
for a duration of time necessary for the hemoglobin to be
maintained at least at 8.0 g/dI.
[0017] In some embodiments, a method encompassed by this disclosure
includes a method for treating a subject having an immune disorder
other than paraneoplastic pemphigus, pemphigus foliaceus, or
pemphigus vulgaris, including administering a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug to the subject,
such that the subject's immune system reconstitutes without both
stem cell transplantation and administration of additional
immunomodulatory agents, and where the method does not include
administration of platelets.
[0018] In some methods encompassed by this disclosure, an effective
amount of granulocyte colony stimulating factor is 5 .mu.g/kg/day,
which is administered for a duration of time necessary for the
neutrophil count to be at least 1000/mm.sup.3. In some embodiments,
methods encompassed by this disclosure include administration of an
effective amount of NEULASTA.RTM..
[0019] In some embodiments, a method of treating an immune disorder
includes administering to a subject in need thereof, a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug
followed by, administering an effective amount of granulocyte
colony stimulating factor to the subject; and administering an
effective amount of at least one antimicrobial agent to the
subject, where the method does not include all three of (a) stem
cell transplantation; (b) administration of additional
immunomodulatory agents; and (c) administration of platelets.
[0020] In further embodiments, this disclosure relates to a method
of obtaining a cell population substantially free of cells capable
of eliciting an adverse immune reaction in a subject, including:
(a) administering a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug to the subject, followed by, (b)
administering an effective amount of granulocyte colony stimulating
factor to the subject; (c) administering an effective amount of at
least one antimicrobial agent to the subject; and (d) administering
an effective amount of platelets to the subject, where the method
does not include the use of both stem cell transplantation and
administration of additional immunomodulatory agents. Exemplary
additional immunomodulatory agents include but are not limited to,
for example, prednisone, cyclosporine, methotrexate, tacrolimus,
pimecrolimus and azathioprine. The high dose cyclophosphamide
therapy described herein is more effective than the low-dose
therapy, which usually requires daily oral dosing or monthly
intravenous pulses at 500-1000 mg/m.sup.2 and has a higher risk of
malignancies and premature menopause and/or infertility.
[0021] In addition to autoimmune diseases, this disclosure also
encompasses the treatment of other adverse immune reactions such as
allergic reactions and transplant rejections. Examples of allergic
reactions which may be treated using methods described herein
include, but are not limited to, for example, systemic allergic
reactions, allergic reactions to immunotherapy, anaphylactic
reactions, atopic disease, contrast allergy, drug allergies, food
allergies such as, for example, shellfish and peanut allergies,
hypersensitivity reactions, insect sting allergies, latex allergy,
penicillin allergy, and radiocontrast medium allergy.
[0022] Examples of transplant rejections which may be treated using
methods described herein include, for example, transplant rejection
occurring during or following allogenic antigen transplantation of
organs, tissues, or cells into a host; transplant rejection
occurring during or following a xenogenic transplantation of
organs, tissues, or cells into a host; and transplant rejection
occurring during or following transplantation of autologous tissue,
organs or cells into a host. Transplant rejections also include
rejections occurring during or following transplantation of an
organ, tissue or hematopoietic stem cells from related (matched or
partially matched) or unrelated donors. Transplant rejections after
stem cell transplantation include both graft rejection and
graft-versus-host disease without wishing to be bound by theory, it
is contemplated that any disease which can be effectively treated
by eliminating the subject's circulating immune cells with high
dose cyclophosphamide and allowing them to redevelop from
hematopoietic stem cells is encompassed by this disclosure.
[0023] Accordingly, diseases which may be treated by the methods
described herein include, but are not limited to, AIDS-associated
myopathy, AIDS-associated neuropathy, Acute disseminated
encephalomyelitis, Addison's Disease, Alopecia Areata, Anaphylaxis
Reactions, Ankylosing Spondylitis, Antibody-related Neuropathies,
Antiphospholipid Syndrome, Autism, Autoimmune Atherosclerosis,
Autoimmune Diabetes Insipidus, Autoimmune Endometriosis, Autoimmune
Eye Diseases, Autoimmune Gastritis, Autoimmune Hemolytic Anemia,
Autoimmune Hemophilia, Autoimmune Hepatitis, Autoimmune
Interstitial Cystitis, Autoimmune Lymphoproliferative Syndrome,
Autoimmune Myelopathy, Autoimmune Myocarditis, Autoimmune
Neuropathies, Autoimmune Oophoritis, Autoimmune Orchitis,
Autoimmune Thrombocytopenia, Autoimmune Thyroid Diseases,
Autoimmune Urticaria, Autoimmune Uveitis, Autoimmune Vasculitis,
Behcet's Disease, Bell's Palsy, Bullous Pemphigoid, CREST, Celiac
Disease, Cerebellar degeneration (paraneoplastic), Chronic Fatigue
Syndrome, Chronic Rhinosinusitis, Chronic inflammatory
demyelinating polyneuropathy, Churg Strauss Syndrome, Connective
Tissue Diseases, Crohn's Disease, Cutaneous Lupus, Dermatitis
Herpetiformis, Dermatomyositis, Diabetes Mellitus, Discoid Lupus
Erythematosus, Drug-induced Lupus, Endocrine Orbitopathy,
Glomerulonephritis, Goodpasture Syndrome, Goodpasture's Syndrome,
Graves Disease, Guillian-Barre Syndrome, Miller Fisher variant of
the Guillian Barre Syndrome, axonal Guillian Barre Syndrome,
demyelinating Guillian Barre Syndrome, Hashimoto Thyroiditis,
Herpes Gestationis, Human T-cell lymphomavirus-associated
myelopathy, Huntington's Disease, IgA Nephropathy, Immune
Thrombocytopenic Purpura, Inclusion body myositis, Interstitial
Cystitis, Isaacs syndrome, Lambert Eaton myasthenic syndrome,
Limbic encephalitis, Lower motor neuron disease, Lyme Disease,
MCTD, Microscopic Polyangiitis, Miller Fisher Syndrome, Mixed
Connective Tissue Disease, Mononeuritis multiplex (vasculitis),
Multiple Sclerosis, Myasthenia Gravis, Myxedema, Meniere Disease,
Neonatal LE, Neuropathies with dysproteinemias,
Opsoclonus-myoclonus, PBC, POEMS syndrome, Paraneoplastic
Autoimmune Syndromes, Pemphigus, Pemphigus Foliaceus, Pemphigus
Vulgaris, Pernicious Anemia, Peyronie's Disease,
Plasmacytoma/myeloma neuropathy, Poly-Dermatomyositis,
Polyarteritis Nodosa, Polyendocrine Deficiency Syndrome,
Polyendocrine Deficiency Syndrome Type 1, Polyendocrine Deficiency
Syndrome Type 2, Polyglandular Autoimmune Syndrome Type I,
Polyglandular Autoimmune Syndrome Type II, Polyglandular Autoimmune
Syndrome Type III, Polymyositis, Primary Biliary Cirrhosis, Primary
Glomerulonephritis, Primary Sclerosing Cholangitis, Psoriasis,
Psoriatic Arthritis, Rasmussen's Encephalitis, Raynaud's Disease,
Relapsing Polychondritis, Retrobulbar neuritis, Rheumatic Diseases,
Rheumatoid Arthritis, Scleroderma, Sensory neuropathies
(paraneoplastic), Sjogren's Syndrome, Stiff-Person Syndrome,
Subacute Thyroiditis, Subacute autonomic neuropathy, Sydenham
Chorea, Sympathetic Ophthalmitis, Systemic Lupus Erythematosus,
Transverse myelitis, Type 1 Diabetes, Ulcerative Colitis,
Vasculitis, Vitiligo, Wegener's Granulomatosis, Acrocyanosis,
Anaphylactic reaction, Autoimmune inner ear disease, Bilateral
sensorineural hearing loss, Cold agglutinin hemolytic anemia,
Cold-induced immune hemolytic anemia, Idiopathic endolymphatic
hydrops, Idiopathic progressive bilateral sensorineural hearing
loss, Immune-mediated inner ear disease, and Mixed autoimmune
hemolysis.
[0024] In some embodiments, this disclosure relates to the
treatment of scleroderma in a subject including administration of a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug
to the subject, thereby to treat scleroderma.
[0025] In some embodiments, a lymphocytotoxic non-myeloablative
amount of a oxazaphosphorine drug used in the methods described
herein is between 100 mg/kg and 200 mg/kg, administered daily from
1 to 7 days. In some embodiments, a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug is between 25
mg/kg and 100 mg/kg, administered daily for 4 consecutive days. In
certain embodiments, a lymphocytotoxic non-myeloablative amount of
a oxazaphosphorine drug is 50 mg/kg administered daily for 4
consecutive days.
[0026] Exemplary oxazaphosphorine drugs include, but are not
limited to, cyclophosphamide, ifosfamide, perfosfamide,
trophosphamide (trofosfamide), or a pharmaceutically acceptable
salt, solvate, prodrug and metabolite thereof. In some embodiments,
a oxazaphosphorine drug used in the methods described herein is
cyclophosphamide or a pharmaceutically acceptable salt or
metabolite thereof.
[0027] Exemplary antimicrobial drugs used in the methods described
herein include, but are not limited to, Amdinocillin (Mecillinam),
Amikacin, Amoxicillin, Ampicillin, Azithromycin, Aztreonam,
Bacampicillin, Bacitracin, Carbenicillin indanyl sodium, Cefaclor,
Cefadroxil, Cefamandole, Cefazolin, Cefdinir, Cefditoren, Cefepime,
Cefixime, Cefinetazole, Cefonicid, Cefoperazone, Cefotaxime,
Cefotetan, Cefoxitin, Cefpodoxime Proxetil, Cefprozil, Ceftazidime,
Ceftibuten, Ceftizoxime, Ceftriaxone, Cefuroxime, Cefuroxime
axetil, Cephalexin, Cephalothin, Cephapirin, Cephradine,
Chloramphenicol, Cnnoxacin, Ciprofloxacin, Clarithromycin,
Clindamycin, Cloxacillin, Colistimethate, Daptomycin,
Demeclocycline, Dicloxacillin, Dirithromycin, Doxycycline,
Enoxacin, Ertapenem, Erythromycin, Fosfomycin, Gatifloxacin,
Gemifloxacin, Gentamicin, Grepafloxacin, Imipenem/Cilastatin,
Kanamycin, Levofloxacin, Lincomycin, Linezolid, Lomefloxacin,
Loracarbef, Mafenide, Meropenem, Methacycline, Methenamine
mandelate, Methenamine hippurate, Methicillin, Metronidazole,
Mezlocillin, Minocycline, Moxifloxacin, Mupirocin, Nafcillin,
Nalidixic Acid, Neomycin, Netilmycin, Nitrofurantoin,
Nitrofurazone, Norfloxacin, Novobiocin, Ofloxacin, Oxacillin,
Oxytetracycline, Penicillin, Piperacillin, Polymyxin B, Rifamixin,
Sparfloxacin, Spectinomycin, Streptomycin, Sulfadiazine,
Sulfamethoxazole, Sulfisoxazole, Teicoplanin, Telithromycin,
Tetracycline, Ticarcillin, Tobramycin, Trimethoprim, Trovafloxacin,
Vancomycin, and a pharmaceutically acceptable salt or derivative
thereof.
[0028] Exemplary combinations of antimicrobial agents include, but
are not limited to, for example, Amoxicillin plus Clavulanate,
Ticarcillin plus Clavulanic Acid, Trimethoprim plus
Sulfamethoxazole, Piperacillin plus Tazobactam, Quinupristin plus
Dalfopristin, and Ampicillin plus Sulbactam.
[0029] In certain embodiments, an antimicrobial agent is chosen
from the group consisting of Amphotericin B, Amphotericin B
Deoxycholate, Amphotericin B cholesteryl sulfate complex (ABCD),
Amphotericin B lipid complex (ABLC), Amphotericin B liposomal,
Caspofungin acetate, Clotrimazole, Fluconazole, Flucytosine,
Griseofulvin, Itraconazole, Ketoconazole, Miconazole, Nystatin,
Pentamidine, Terbinafine, and Voriconazole.
[0030] In some embodiments, methods encompassed by this disclosure
further include administration of an antiviral drug. Antiviral
drugs include, but are not limited to, Abacavir, Aciclovir,
Amantadine, Didanosine, Emtricitabine, Enfuvirtide, Entecavir,
Lamivudine, Nevirapine, Ribavirin, Rimantidine, Stavudine,
Valaciclovir, Vidarabine, Zalcitabine, and Zidovudine.
[0031] Also encompassed by this disclosure is a kit for treating an
immune disorder including: (a) a plurality of doses of a
non-myeloablative oxazaphosphorine drug; and (b) instructions for
treating the immune disorder using one or more doses of the
oxazaphosphorine drug; wherein the one or more doses are
lymphocytotoxic.
[0032] In some embodiments, a kit for treating an immune disorder
further includes one or more of: (a) a plurality of doses of
granulocyte colony stimulating factor; (b) a plurality of doses of
platelets; and (d) a plurality of doses of one or more
antimicrobial agent.
[0033] The kits encompassed by this disclosure can be used for
treating an immune disorder chosen from an autoimmune disease, an
allergic reaction and transplant rejection.
DETAILED DESCRIPTION
[0034] This disclosure is based, at least in part, on the discovery
that administration of a lymphocytotoxic non-myeloablative amount
of a oxazaphosphorine drug can be used for replacing a subject's
immune cells, including autoreactive lymphocytes, with disease-free
immune cells, without the use of both stem cell transplantation and
additional immunomodulatory agents.
[0035] The rationale underlying this approach is the discovery that
oxazaphosphorine drugs such as cyclophosphamide are lymphocytotoxic
but spare hematopoietic progenitor stem cells because of high
levels of aldehyde dehydrogenase, an enzyme, which confers
resistance to cyclophosphamide.
[0036] High-dose cyclophosphamide was originally used in allogeneic
bone marrow transplantation because of its ability to break immune
tolerance and facilitate engraftment. (See, for example, Santos et
al., Transplant Proc., 4: 559-564 (1972)).
[0037] As a prodrug, cyclophosphamide is converted to
4-hydroxycyclophosphamide and its tautomer aldophosphamide in the
liver. These compounds diffuse into cells and are converted into
the active compound phosphoramide mustard. Alternatively, they are
inactivated by the enzyme aldehyde dehydrogenase to form the inert
carboxyphosphamide. Lymphoid cells, including NK cells, and B and T
lymphocytes, have low levels of aldehyde dehydrogenase and are
rapidly killed by high doses (i.e., lymphocytotoxic) of
cyclophosphamide. In contrast, hematopoietic progenitor stem cells
possess high levels of aldehyde dehydrogenase, rendering them
resistant to cyclophophamide. (See, for example, Hilton, Cancer
Res., 44:5156-60 (1984); Kastan et al., Blood, 75:1947-50 (1990);
Zoumbos et al., N. Eng. J. Med., 312:257-265 (1985); Brodsky, Sci.
World J., 2: 1808-15 (2002)).
1. DEFINITIONS
[0038] In order that the present disclosure may be more readily
understood, certain terms are first defined. Additional definitions
are set forth throughout the detailed description.
[0039] The term "relapse" refers to the recurrence of an immune
disorder after recovery following treatment; and or recurrence of
one or more symptoms associated with an immune disorder after
recovery following treatment. No relapse for at least about four
years is intended to include no relapse between about 3.5 years to
about 4.5 years. No relapse for at least about five years is
intended to include no relapse between about 4.5 to about 5.5
years. No relapse for at least about ten years is intended to
include no relapse between about 9 to about 11 years.
[0040] The term "remission" refers to the disappearance of
autoreactive cells following treatment and/or disappearance of one
or more or all symptoms associated with an adverse immune reaction,
including, for example, an autoimmune disease, an allergic reaction
and transplant rejection.
[0041] As used herein, the phrase "a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug" refers to an
amount of the drug which is immunoablative, upon single or multiple
dose administration to a subject (such as a human patient suffering
from an autoimmune disease, an allergic reaction or transplant
rejection), thereby resulting in a substantial reduction in or
complete elimination of mature circulating lymphocytes in the
subject. In some embodiments, administration of a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug results in
treating, preventing, curing, delaying, reducing the severity of,
ameliorating at least one symptom of a disorder or recurring
disorder, or prolonging the survival of the subject beyond that
expected in the absence of such administration. In some
embodiments, "a lymphocytotoxic non-myeloablative amount of an
oxazaphosphorine drug" refers to a dose of the drug administered to
a subject in need thereof, which results in eliminating or
substantially reducing the number of circulating lymphocytes in the
subject, including those which are associated with an adverse
immune reaction such as, for example, an autoimmune disease,
transplant rejection and allergic reaction, while sparing the
hematopoietic progenitor stem cells. For example, in some
embodiments, "a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug" is a 50 mg/kg/day dose of cyclophosphamide
administered to a subject in need thereof for 4 consecutive
days.
[0042] The phrase "granulocyte colony stimulating factor" or "GCSF"
refers to a hematopoietic growth factor that stimulates the
development of committed progenitor cells to neutrophils and
enhances the functional activities of neutrophils. It is produced
in response to specific stimulation by a variety of cells including
macrophages, fibroblasts, endothelial cells and bone marrow stroma.
GCSF can be used clinically to facilitate hematopoietic recovery
after bone marrow transplantation. In some embodiments described
herein, GCSF is administered to increase the neutrophil count to a
level, which falls within a normal range. Either purified GCSF or
recombinant GCSF, for example, recombinant human GCSF (R & D
SYSTEMS, INC, Minneapolis, Minn.) can be used in the methods
described herein.
[0043] The phrase "an effective amount of granulocyte colony
stimulating factor" refers to an amount of granulocyte colony
stimulating factor, which upon a single or multiple dose
administration to a subject, results in an elevation in neutrophil
count in the subject. Elevation in neutrophil count includes any
measurable increase in neutrophil count or appearance of
neutrophils following administration of an effective amount of
granulocyte colony stimulating factor. A measurable increase can
be, for example, a 5-fold, or a 10-fold, or a 15-fold, or a
20-fold, or a 25-fold, or a 30-fold, or a 40-fold, or a 50-fold, or
a 60-fold, or a 70-fold, or a 80-fold, or a 90-fold, or a 100-fold,
or greater than a 100-fold increase in neutrophil count following
administration of an effective amount of granulocyte colony
stimulating factor. In some embodiments, an elevation in neutrophil
count includes elevation to a count that is within a normal range,
as understood by one of ordinary skill in the art. In some
embodiments, "an effective amount of granulocyte colony stimulating
factor" refers to a daily administration of 5 .mu.g/kg of the
granulocyte colony stimulating factor.
[0044] The phrase "an effective amount of an antimicrobial agent"
refers to an amount of one or more than one agent with an
antimicrobial activity, which upon a single or multiple dose
administration to a subject, results in an elevation in leukocyte
count in the subject. Elevation in leukocyte count includes any
measurable increase in leukocyte count or appearance of leukocytes
following administration of an effective amount of an antimicrobial
agent. A measurable increase can be, for example, a 5-fold, or a
10-fold, or a 15-fold, or a 20-fold, or a 25-fold, or a 30-fold, or
a 40-fold, or a 50-fold, or a 60-fold, or a 70-fold, or a 80-fold,
or a 90-fold, or a 100-fold, or greater than a 100-fold increase in
leukocyte count following administration of an effective amount of
at least one antimicrobial agent. In some embodiments, an elevation
in leukocyte count includes elevation to a count which is within a
normal range, as understood by one or ordinary skill in the
art.
[0045] The term "within a normal range" refers to a certain
measurement, for example, number of cells or cell count, in a
healthy subject. It would be apparent to one of ordinary skill in
the art whether a particular indicia being measured is within "a
normal range."
[0046] The term "use of additional immunomodulatory agents," as
used herein, refers to the use of any agent, other than a
oxazaphosphorine drug, which is capable of modulating the immune
system (e.g., by increasing or decreasing an immune response;
increasing or decreasing activity of one or more immune cells
and/or activating or suppressing the immune system), in the methods
described herein. For example, in some embodiments,
immunomodulatory agents include immunosuppressive agents, other
than a oxazaphosphorine agent such as cyclophosphamide, which when
administered at an appropriate dosage, results in the inhibition of
an immune response, for example, inhibition of T cell activity.
Examples of such agents include, but are not limited to,
prednisone, cyclosporine, FK-506, and rapamycin. In some
embodiments, exclusion of any additional immunomodulatory agents in
methods described herein, refers to exclusion of additional
immunosuppressive agents subsequent to, or concurrently with the
administration of a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug.
[0047] Methods which do not include the use of "any additional
immunomodulatory agents," specifically exclude the use of agents
which are immunosuppressive, such as, for example, prednisone, in
methods which use a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug.
[0048] The terms "treat," "treating," and "treatment," as used
herein, refer to therapeutic or preventative measures described
herein. The methods of "treatment" employ administration to a
subject in need thereof such as, for example, a subject having an
autoimmune disease, an allergic reaction or transplant rejection,
or who ultimately may acquire a disorder such as, for example, an
autoimmune disease, an allergic reaction or transplant rejection, a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine
drug, such as, for example, cyclophosphamide, in order to prevent,
cure, delay, reduce the severity of, or ameliorate one or more
symptoms of the disorder or recurring disorder, or in order to
prolong the survival of a subject beyond that expected in the
absence of such treatment.
[0049] The terms "cure" and "curing," as used herein, refer to a
remission of a disease or an elimination of symptoms (e.g.,
clinical, laboratory, and imaging) of a disease in a subject such
as, for example, an autoimmune disease, an allergic reaction or
transplant rejection, by the methods described herein. The
remission of a disease or the elimination of symptoms of a disease
in a subject maybe for at least about 1 year, at least about 2
years, at least about 3 years, at least about 4 years, or at least
about 5 years. In certain embodiments, a remission of a disease or
an elimination of symptoms of a disease in a subject includes the
absence of administering alternative methods of treatment such as
immunosuppressants (e.g., cyclosporine, cyclophosphamide, etc),
and/or steroids. In some embodiments, a method of curing an immune
disorder includes administration of a lymphocytotoxic
non-myeloablative amount of an oxazaphosphorine drug to a subject
in need thereof, where the immune disorder is not severe aplastic
anemia, chronic inflammatory demyelinating polyneuropathy,
paraneoplastic pemphigus, paraneoplastic pemphigus, pemphigus
foliaceus, or pemphigus vulgaris.
[0050] The term "an oxazaphosphorine drug" refers to a class of
drugs, which act as alkylating agents and cause immunoablation.
They are generally highly cytotoxic and are often used as
chemotherapeutic agents. Examples of oxazaphosphorine drugs include
cyclophosphamide, ifosfamide, perfosfamide, trophosphamide
(trofosfamide), and pharmaceutically acceptable salts, solvates,
prodrugs and metabolites thereof. In some embodiments, an
oxazaphosphorine drug used in the methods described herein is
cyclophosphamide, which is sold under common trade-names including
PROCYTOX.RTM., CYTOXAN.RTM. and NEOSAR.RTM.. As discussed above,
cyclophosphamide is converted to 4-hydroxycyclophosphamide and its
tautomer aldophosphamide in the liver and is cytotoxic to cells
that express low levels of the enzyme aldehyde dehydrogenase, for
example, NK cells and T and B lymphocytes.
[0051] Ifosfamide (MITOXANAO) is a structural analog of
cyclophosphamide and its mechanism of action is considered to be
identical or substantially similar to that of cyclophosphamide.
Perfosfamide (4hydroperoxycyclophosphamide) and trophosphamide are
also alkylating agents, which are structurally related to
cyclophosphamide. For example, perfosfamide alkylates DNA, thereby
inhibiting DNA replication and RNA and protein synthesis.
[0052] The term "hematopoietic progenitor stem cell," as used
herein refers to any type of cell of the hematopoietic system,
including, but not limited to, undifferentiated cells such as
hematopoietic stem cells and progenitor cells, which are capable of
reconstituting the immune system following administration of a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine
drug, as described herein.
[0053] The terms "immunoablation" and "immunoablative," as used
herein, refer to severe immunosuppression using a high-dose (i.e.,
lymphocytotoxic non-myeloablative amount) of a oxazaphosphorine
drug such as, for example, 50 mg/kg.times.4 days of
cyclophosphamide, which leads to substantial reduction in or
elimination of the population of circulating lymphocytes, including
for example, NK cells and B and T lymphocytes. Immunoablation, as
described herein, results in complete or substantially complete
reduction in autoreactive antibodies and memory cells responsible
for an autoimmune response.
[0054] The term "lymphocytotoxic," as used herein, refers to
complete elimination of or substantial reduction in the number of
circulating lymphocytes, including those associated with an adverse
immune reaction in a subject, such as, for example, an autoimmune
disease, an allergic reaction and transplant rejection in a subject
following administration of a high-dose (i.e., lymphocytotoxic
non-myeloablative amount) of a oxazaphosphorine drug, such as, for
example, 50 mg/kg.times.4 days of cyclophosphamide. Substantial
reduction can be a reduction of about 5%, 10%, 15%, 20%, 25%, 50%,
75%, 90%, 95%, 98%, 99% of the circulating lymphocytes. The term
"lymphocytotoxic," includes killing of those immune cells by a
oxazaphosphorine drug which express low levels of the enzyme
aldehyde dehydrogenase.
[0055] The term "non-myeloablative," as used herein, refers to a
property of a compound such as, for example, an oxazaphosphorine
drug such as cyclophosphamide, whereby the compound does not have a
detectable or significant cytotoxic effect on myeloid cells, for
example, hematopoietic progenitor stem cells. In some embodiments,
a non-myeloablative agent used in the methods described herein has
a cytotoxic effect on the circulating mature lymphocytes (e.g., NK
cells, and T and B lymphocytes) while sparing the progenitor cells,
e.g., hematopoietic progenitor stem cells that are capable of
reconstituting the immune system. In some embodiments, a
non-myeloablative agent used in the methods of the invention kills
cells which express low levels of the enzyme aldehyde dehydrogenase
(e.g., NK cells and B and T lymphocytes) while sparing cells which
express high levels of the enzyme aldehyde dehydrogenase (e.g.,
hematopoietic progenitor stem cells).
II. EXEMPLARY DISORDERS
[0056] Various methods described herein can be used for treating
autoimmune diseases, allergic reactions and transplant
rejection.
[0057] Exemplary autoimmune diseases which can be treated using
methods described herein include, but are not limited to,
AIDS-associated myopathy, AIDS-associated neuropathy, Acute
disseminated encephalomyelitis, Addison's Disease, Alopecia Areata,
Anaphylaxis Reactions, Ankylosing Spondylitis, Antibody-related
Neuropathies, Antiphospholipid Syndrome, Autism, Autoimmune
Atherosclerosis, Autoimmune Diabetes Insipidus, Autoimmune
Endometriosis, Autoimmune Eye Diseases, Autoimmune Gastritis,
Autoimmune Hemolytic Anemia, Autoimmune Hemophilia, Autoimmune
Hepatitis, Autoimmune Interstitial Cystitis, Autoimmune
Lymphoproliferative Syndrome, Autoimmune Myelopathy, Autoimmune
Myocarditis, Autoimmune Neuropathies, Autoimmune Oophoritis,
Autoimmune Orchitis, Autoimmune Thrombocytopenia, Autoimmune
Thyroid Diseases, Autoimmune Urticaria, Autoimmune Uveitis,
Autoimmune Vasculitis, Behcet's Disease, Bell's Palsy, Bullous
Pemphigoid, CREST, Celiac Disease, Cerebellar degeneration
(paraneoplastic), Chronic Fatigue Syndrome, Chronic Rhinosinusitis,
Chronic inflammatory demyelinating polyneuropathy, Churg Strauss
Syndrome, Connective Tissue Diseases, Crohn's Disease, Cutaneous
Lupus, Dermatitis Herpetiformis, Dermatomyositis, Diabetes
Mellitus, Discoid Lupus Erythematosus, Drug-induced Lupus,
Endocrine Orbitopathy, Glomerulonephritis, Goodpasture Syndrome,
Goodpasture's Syndrome, Graves Disease, Guillain-Barre Syndrome,
Guillian Barre Syndrome (Miller Fisher variant), Guillian Bane
Syndrome (axonal), Guillian Bane Syndrome (demyelinating),
Hashimoto's Thyroiditis, Herpes Gestationis, Human T-cell
lymphomavirus-associated myelopathy, Huntington's Disease, IgA
Nephropathy, Immune Thrombocytopenic Purpura, Inclusion body
myositis, Interstitial Cystitis, Isaacs syndrome, Lambert Eaton
myasthenic syndrome, Limbic encephalitis, Lower motor neuron
disease, Lyme Disease, MCTD, Microscopic Polyangiitis, Miller
Fisher Syndrome, Mixed Connective Tissue Disease, Mononeuritis
multiplex (vasculitis), Multiple Sclerosis, Myasthenia Gravis,
Myxedema, Meniere Disease, Neonatal LE, Neuropathies with
dysproteinemias, Opsoclonus-myoclonus, PBC, POEMS syndrome,
Paraneoplastic Autoimmune Syndromes, Pemphigus, Pemphigus
Foliaceus, Pemphigus Vulgaris, Pernicious Anemia, Peyronie's
Disease, Plasmacytoma/myeloma neuropathy, Poly-Dermatomyositis,
Polyarteritis Nodosa, Polyendocrine Deficiency Syndrome,
Polyendocrine Deficiency Syndrome Type 1, Polyendocrine Deficiency
Syndrome Type 2, Polyglandular AutoimmuneSyndrome Type I,
Polyglandular Autoimmune Syndrome Type II, Polyglandular Autoimmune
Syndrome Type III, Polymyositis, Primary Biliary Cirrhosis, Primary
Glomerulonephritis, Primary Sclerosing Cholangitis, Psoriasis,
Psoriatic Arthritis, Rasmussen's Encephalitis, Raynaud's Disease,
Relapsing Polychondritis, Retrobulbar neuritis, Rheumatic Diseases,
Rheumatoid Arthritis, Scleroderma, Sensory neuropathies (para neo
plastic), Sjogren's Syndrome, Stiff-Person Syndrome, Subacute
Thyroiditis, Subacute autonomic neuropathy, Sydenham Chorea,
Sympathetic Ophthalmitis, Systemic Lupus Erythematosus, Transverse
myelitis, Type 1 Diabetes, Ulcerative Colitis, Vasculitis,
Vitiligo, Wegener's Granulomatosis, Acrocyanosis, Anaphylactic
reaction, Autoimmune inner ear disease, Bilateral sensorineural
hearing loss, Cold agglutinin hemolytic anemia, Cold-induced immune
hemolytic anemia, Idiopathic endolymphatic hydrops, Idiopathic
progressive bilateral sensorineural hearing loss, Immune-mediated
inner ear disease, and Mixed autoimmune hemolysis.
[0058] Without wishing to be bound by theory, it is understood that
methods described herein can be used for treating any immune
disorder in which it would be desirable to replace the circulating
auto-reactive lymphocytes with disease free immune cells. One of
ordinary skill in the art can easily determine which diseases fall
in this category, for example, by detecting auto-reactive
antibodies or antibodies which react with self-antigens in a
subject suffering from such a disease. Alternatively, by detecting
cells in a subject which are capable of mounting an immune response
against a self-antigen in the subject. Methods of diagnosing one or
more autoimmune diseases encompassed by this disclosure are
well-known in the art and can easily be performed by a skilled
artisan.
[0059] In addition to autoimmune diseases, also encompassed by this
disclosure are allergic reactions, which can be treated by methods
described herein. Exemplary allergic reactions include, but are not
limited to, systemic allergic reaction, an allergic reaction to
immunotherapy, anaphylactic reaction, atopic disease, contrast
allergy, drug allergy, food allergy, hypersensitivity reaction,
insect sting allergy, latex allergy, penicillin allergy, and
radiocontrast medium allergy. Examples of food allergies include an
allergic reaction to peanuts or shellfish, for example.
[0060] In addition to autoimmune diseases and allergic reactions,
also encompassed by this disclosure are transplant rejections that
can be treated using methods described herein. For example, in some
embodiments, transplant rejection occurring during or following an
allogenic antigen transplantation of organs, tissues, or cells into
a host can be treated using methods described herein. In certain
embodiments, transplant rejection occurring during or following a
xenogenic transplantation of organs, tissues, or cells into a host
can be treated using methods described herein. In certain
embodiments, transplant rejection occurring during or following
transplantation of autologous tissue, organs or cells into a host
can be treated using methods described herein.
[0061] Also encompassed by this disclosure are transplant
rejections occurring during or following a transplant of an organ,
tissue or cells from a half-matched donor, which usually results in
graft versus host disease.
III. EXEMPLARY ANTIMICROBIAL AND ANTIVIRAL AGENTS
[0062] Exemplary antimicrobial drugs used in the methods described
herein include, but are not limited to, Amdinocillin (Mecillinam),
Amikacin, Amoxicillin, Ampicillin, Azithromycin, Aztreonam,
Bacampicillin, Bacitracin, Carbenicillin indanyl sodium, Cefaclor,
Cefadroxil, Cefamandole, Cefazolin, Cefdinir, Cefditoren, Cefepime,
Cefixime, Cefinetazole, Cefonicid, Cefoperazone, Cefotaxime,
Cefotetan, Cefoxitin, Cefpodoxime Proxetil, Cefprozil, Ceftazidime,
Ceftibuten, Ceftizoxime, Ceftriaxone, Cefuroxime, Cefuroxime
axetil, Cephalexin, Cephalothin, Cephapirin, Cephradine,
Chloramphenicol, Cinoxacin, Ciprofloxacin, Clarithromycin,
Clindamycin, Cloxacillin, Colistimethate, Daptomycin,
Demeclocycline, Dicloxacillin, Dirithromycin, Doxycycline,
Enoxacin, Ertapenem, Erythromycin, Fosfomycin, Gatifloxacin,
Gemifloxacin, Gentamicin, Grepafloxacin, Imipenem/Cilastatin,
Kanamycin, Levofloxacin, Lincomycin, Linezolid, Lomefloxacin,
Loracarbef, Mafenide, Meropenem, Methacycline, Methenamine
mandelate, Methenaminehippurate, Methicillin, Metronidazole,
Mezlocillin, Minocycline, Moxifloxacin, Mupirocin, Nafcillin,
Nalidixic Acid, Neomycin, Netilmycin, Nitrofurantoin,
Nitrofurazone, Norfloxacin, Novobiocin, Ofloxacin, Oxacillin,
Oxytetracycline, Penicillin, Piperacillin, Polymyxin B, Rifamixin,
Sparfloxacin, Spectinomycin, Streptomycin, Sulfadiazine,
Sulfamethoxazole, Sulfisoxazole, Teicoplanin, Telithromycin,
Tetracycline, Ticarcillin, Tobramycin, Trimethoprim, Trovafloxacin,
Vancomycin and a pharmaceutically acceptable salt or derivative
thereof.
[0063] Various anti-microbial agents used in the methods described
herein can either be used alone or in combination with another
antimicrobial agent, so long as the antimicrobial agents alone or
in combination result in an increase in leukocyte count which is
within a normal range and so long as the antimicrobial agents do
not have an adverse reaction with each other or with any other
compounds administered in the methods described herein. One skilled
in the art can easily determine whether to use a single
antimicrobial agent in the methods or a combination of agents using
the standard techniques known in the art and those described
herein. In some embodiments, choice of an antimicrobial agent may
depend on the susceptibility of a subject being treated to an
infection, for example, a bacterial infection. In certain
embodiments, choice of an antimicrobial agent may depend on the
occurrence of such an infection in the subject being treated.
[0064] Exemplary combinations of antimicrobial agents include, but
are not limited to, for example, Amoxicillin plus Clavulanate,
Ticarcillin plus Clavulanic Acid, Trimethoprim plus
Sulfamethoxazole, Piperacillin plus Tazobactam, Quinupristin plus
Dalfopristin, and Ampicillin plus Sulbactam.
[0065] In certain embodiments, an antimicrobial agent is chosen
from the group consisting of Amphotericin B, Amphotericin B
Deoxycholate, Amphotericin B cholesteryl sulfate complex (ABCD),
Amphotericin B lipid complex (ABLC), Amphotericin B liposomal,
Caspofungin acetate, Clotrimazole, Fluconazole, Flucytosine,
Griseofulvin, Itraconazole, Ketoconazole, Miconazole, Nystatin,
Pentamidine, Terbinafine, and Voriconazole.
[0066] In some embodiments, methods encompassed by this disclosure
further include administration of an antiviral drug. Antiviral
drugs include, but are not limited to, Abacavir, Aciclovir,
Amantadine, Didanosine, Emtricitabine, Enfuvirtide, Entecavir,
Lamivudine, Nevirapine, Ribavirin, Rimantidine, Stavudine,
Valaciclovir, Vidarabine, Zalcitabine, and Zidovudine.
IV. EXEMPLARY PHARMACEUTICAL COMPOSITIONS
[0067] The disclosure also pertains to pharmaceutical compositions
including one or more compounds used in the methods described
herein and a pharmaceutically acceptable diluent or carrier. Such
pharmaceutical compositions may be included in a kit or container.
Such kit or container maybe packaged with instructions pertaining
to the method of treating a disease, as described herein. Such
compositions may be used in methods of curing, treating,
preventing, or ameliorating a disease or a disease symptom in a
patient, preferably a mammal and most preferably a human, by using
the methods described herein. The compositions described herein may
also comprise a combination of lymphocytoxic non-myeloablative
amount of an oxazaphosphorine drug and at least one other agent,
for example, granulocyte colony stimulating factor and an
antimicrobial agent. Also provided herein is a composition
comprising a combination of lymphocytoxic non-myeloablative amount
of an oxazaphosphorine drug and at least one other agent, wherein
platelets are administered prior to, simultaneously, or following
administration of the oxazaphosphorine composition.
[0068] For example, in some embodiments, encompassed by this
disclosure is a kit for treating an immune disorder chosen from an
autoimmune disease, an allergic reaction and transplant rejection
including: (a) a plurality of doses of a non-myeloablative
oxazaphosphorine drug; and (b) instructions for treating the immune
disorder using one or more doses of the oxazaphosphorine drug;
wherein the one or more doses are lymphocytotoxic.
[0069] In some embodiments, a kit for treating an immune disorder
chosen from an autoimmune disease, an allergic reaction and
transplant rejection further includes one or more of: (a) a
plurality of doses of granulocyte colony stimulating factor; (b) a
plurality of doses of platelets; and (d) a plurality of doses of
one or more antimicrobial agent.
[0070] In further embodiments, kits encompassed by this disclosure
include instructions for using the kit to treat an immune disorder
chosen from an autoimmune disease, an allergic reaction and
transplant rejection.
V. MODES OF ADMINISTRATION
[0071] The various compounds used in the methods described herein
may be administered orally, parenterally (e.g., intravenously),
intramuscularly, sublingually, buccally, rectally, intranasally,
intrabronchially, intrapulmonarily, intraperitonealy, topically,
transdermally and subcutaneously, for example. The amount of
compound administered in a single dose may dependent on the subject
being treated, the subject's weight, the manner of administration
and the judgment of the prescribing physician. Generally, however,
administration and dosage and the duration of time for which a
composition is administered will approximate that which are
necessary to achieve a desired result, for example, at least a
single dose of 5 .mu.g/kg of granulocyte colony stimulating factor
for increasing neutrophil count to a level which falls within a
normal range. Generally, GCSF is administered at 5
micrograms/kg/daily starting 6 days after the last dose of
cyclophosphamide and is continued the drug until the absolute
neutrophil count reaches 1000. In some embodiments, NEULASTA.RTM.
is administered in place of GCSF.
[0072] For example, in some embodiments, a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug used in the
methods described herein is between 100 mg/kg and 200 mg/kg,
administered daily from 1 to 7 days. In certain embodiments, an
effective amount of a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug is between 25 mg/kg and 100 mg/kg,
administered daily for 2 to 6 consecutive days or administered
daily for 3 to 5 consecutive days, for example 4 consecutive days.
In certain embodiments, a lymphocytotoxic non-myeloablative amount
of a oxazaphosphorine drug is about 50 mg/kg administered daily for
4 consecutive days. In certain embodiments, a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug is 50 mg/kg
administered daily for 4 consecutive days.
[0073] In some embodiments, an effective amount of platelets are
administered to a subject in need thereof for a duration of time
necessary for the platelet count to be, for example, between
100,000 platelets/mm.sup.3 and 110,000 platelets/mm.sup.3, or
between 110,000 platelets/mm.sup.3 and 120,000 platelets/mm.sup.3,
or between 120,000 platelets/mm.sup.3 and 130,000
platelets/mm.sup.3, or greater than 130,000 platelets/mm.sup.3. In
some embodiments, platelets are administered to a subject in need
thereof, for a duration of time necessary for the platelet count to
be at least 10,000 platelets/mm.sup.3.
[0074] In some embodiments, an effective amount of granulocyte
colony stimulating factor is administered for a duration of time
necessary for the neutrophil count to be at least 500/mm.sup.3, or
at least 1000/mm.sup.3, or at least 1500/mm.sup.3, or greater than
1500/mm.sup.3.
[0075] In some methods encompassed by this disclosure, an effective
amount of granulocyte colony stimulating factor is 5
.mu.g/kg/mg/day, which is administered for a duration of time
necessary for the neutrophil count to be at least
1000/mm.sup.3.
[0076] The optimal dosages for administration include those
described herein and those, which may be routinely determined by a
skilled artisan using well-known techniques.
[0077] Depending on the intended mode of administration, the
compounds used in the methods described herein may be in the form
of solid, semi-solid or liquid dosage forms, such as, for example,
tablets, suppositories, pills, capsules, powders, liquids,
suspensions, lotions, creams, gels, or the like, preferably in unit
dosage form suitable for single administration of a precise dosage.
Each dose may include an effective amount of a compound used in the
methods described herein in combination with a pharmaceutically
acceptable carrier and, in addition, may include other medicinal
agents, pharmaceutical agents, carriers, adjuvants, diluents,
etc.
[0078] Liquid pharmaceutically administrable compositions can
prepared, for example, by dissolving, dispersing, etc., a compound
for use in the methods described herein and optional pharmaceutical
adjuvants in an excipient, such as, for example, water, saline
aqueous dextrose, glycerol, ethanol, and the like, to thereby form
a solution or suspension. For solid compositions, conventional
nontoxic solid carriers include, for example, pharmaceutical grades
of mannitol, lactose, starch, magnesium stearate, sodium saccharin,
talc, cellulose, glucose, sucrose, magnesium carbonate, and the
like. If desired, the pharmaceutical composition to be administered
may also contain minor amounts of nontoxic auxiliary substances
such as wetting or emulsifying agents, pH buffering agents and the
like, for example, sodium acetate, sorbitan monolaurate,
triethanolamine sodium acetate, triethanolamine oleate, etc. Actual
methods of preparing such dosage forms are known, or will be
apparent, to those skilled in this art; see, for example,
Remington's Pharmaceutical Sciences, 18th Ed. (1990), Mack
Publishing Co., Easton, Pa., the entire disclosure of which is
hereby incorporated by reference).
VI. METHODS OF TREATMENT
[0079] Methods of treatment described herein encompass methods of
treating an immune disorder including an autoimmune disease, an
allergic reaction and transplant rejection by, for example,
reconstituting a subject's immune system. Also encompassed are
methods of eliminating immune cells, which are capable of eliciting
an adverse immune reaction in a subject. Certain methods described
herein exclude the use of autologous or allogeneic stem cell
transplantation and/or additional immunomodulatory agents.
[0080] Accordingly, in some embodiments, this disclosure provides a
method of treating an immune disorder other than severe aplastic
anemia, chronic inflammatory demyelinating polyneuropathy,
paraneoplastic pemphigus, pemphigus foliaceus, pemphigus vulgaris,
or systemic lupus erythematosus in a subject including
administering a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug to the subject, where the method does not
include the use of both stem cell transplantation and additional
immunomodulatory agents, and where there is no relapse for at least
1 year. In certain embodiments, the disclosure provides a method of
treating an immune disorder, in a subject including administering a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug
to the subject, where the method does not include the use of both
stem cell transplantation and additional immunomodulatory agents,
and where there is no relapse for at least 4 years.
[0081] Methods of treating an immune disorder other than severe
aplastic anemia may additionally include one or more of the steps
of: (a) administering an effective amount of granulocyte colony
stimulating factor to the subject; (b) administering an effective
amount of an antimicrobial agent to the subject; (c) administering
an effective dose of platelets to the subject, and any combinations
thereof.
[0082] In certain embodiments, the disclosure provides methods of
treating an immune disorder including: AIDS-associated myopathy,
AIDS-associated neuropathy, Acute disseminated encephalomyelitis,
Addison's Disease, Alopecia Areata, Anaphylaxis Reactions,
Ankylosing Spondylitis, Antibody-related Neuropathies,
Antiphospholipid Syndrome, Autism, Autoimmune Atherosclerosis,
Autoimmune Diabetes Insipidus, Autoimmune Endometriosis, Autoimmune
Eye Diseases, Autoimmune Gastritis, Autoimmune Hemolytic Anemia,
Autoimmune Hemophilia, Autoimmune Hepatitis, Autoimmune
Interstitial Cystitis, Autoimmune Lymphoproliferative Syndrome,
Autoimmune Myelopathy, Autoimmune Myocarditis, Autoimmune
Neuropathies, Autoimmune Oophoritis, Autoimmune Orchitis,
Autoimmune Thrombocytopenia, Autoimmune Thyroid Diseases,
Autoimmune Urticaria, Autoimmune Uveitis, Autoimmune Vasculitis,
Behcet's Disease, Bell's Palsy, Bullous Pemphigoid, CREST, Celiac
Disease, Cerebellar degeneration (paraneoplastic), Chronic Fatigue
Syndrome, Chronic Rhinosinusitis, Chronic inflammatory
demyelinating polyneuropathy, Churg Strauss Syndrome, Connective
Tissue Diseases, Crohn's Disease, Cutaneous Lupus, Dermatitis
Herpetiformis, Dermatomyositis, Diabetes Mellitus, Discoid Lupus
Erythematosus, Drug-induced Lupus, Endocrine Orbitopathy,
Glomerulonephritis, Goodpasture Syndrome, Goodpasture's Syndrome,
Graves Disease, Guillain-Barre Syndrome, Guillian Barre Syndrome
(Miller Fisher variant), Guillian Bane Syndrome (axonal), Guillian
Bane Syndrome (demyelinating), Hashimoto's Thyroiditis, Herpes
Gestationis, Human T-cell lymphomavirus-associated myelopathy,
Huntington's Disease, IgA Nephropathy, Immune Thrombocytopenic
Purpura, Inclusion body myositis, Interstitial Cystitis, Isaacs
syndrome, Lambert Eaton myasthenic syndrome, Limbic encephalitis,
Lower motor neuron disease, Lyme Disease, MCTD, Microscopic
Polyangiitis, Miller Fisher Syndrome, Mixed Connective Tissue
Disease, Mononeuritis multiplex (vasculitis), Multiple Sclerosis,
Myasthenia Gravis, Myxedema, Meniere Disease, Neonatal LE,
Neuropathies with dysproteinemias, Opsoclonus-myoclonus, PBC, POEMS
syndrome, Paraneoplastic Autoimmune Syndromes, Pemphigus, Pemphigus
Foliaceus, Pemphigus Vulgaris, Pernicious Anemia, Peyronie's
Disease, Plasmacytoma/myeloma neuropathy, Poly-Dermatomyositis,
Polyarteritis Nodosa, Polyendocrine Deficiency Syndrome,
Polyendocrine Deficiency Syndrome Type 1, Polyendocrine Deficiency
Syndrome Type 2, Polyglandular AutoimmuneSyndrome Type I,
Polyglandular Autoimmune Syndrome Type II, Polyglandular Autoimmune
Syndrome Type III, Polymyositis, Primary Biliary Cirrhosis, Primary
Glomerulonephritis, Primary Sclerosing Cholangitis, Psoriasis,
Psoriatic Arthritis, Rasmussen's Encephalitis, Raynaud's Disease,
Relapsing Polychondritis, Retrobulbar neuritis, Rheumatic Diseases,
Rheumatoid Arthritis, Scleroderma, Sensory neuropathies (para neo
plastic), Sjogren's Syndrome, Stiff-Person Syndrome, Subacute
Thyroiditis, Subacute autonomic neuropathy, Sydenham Chorea,
Sympathetic Ophthalmitis, Systemic Lupus Erythematosus, Transverse
myelitis, Type 1 Diabetes, Ulcerative Colitis, Vasculitis,
Vitiligo, Wegener's Granulomatosis, Acrocyanosis, Anaphylactic
reaction, Autoimmune inner ear disease, Bilateral sensorineural
hearing loss, Cold agglutinin hemolytic anemia, Cold-induced immune
hemolytic anemia, Idiopathic endolymphatic hydrops, Idiopathic
progressive bilateral sensorineural hearing loss, Immune-mediated
inner ear disease, and Mixed autoimmune hemolysis, but not
including aplastic anemia, in a subject comprising administering
(a) a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug to the subject, where the method does not
include the use of both stem cell transplantation and additional
immunomodulatory agents, and wherein the method may further
comprise (b) administering an effective amount of granulocyte
colony stimulating factor to the subject; (c) administering an
effective amount of at least one antimicrobial agent to the
subject; and (d) administering an effective amount of platelets to
the subject.
[0083] In further embodiments, this disclosure provides a method
for eliminating or substantially reducing an immune disorder in a
subject other than aplastic anemia, chronic inflammatory
demyelinating polyneuropathy, myasthenia gravis, paraneoplastic
pemphigus, pemphigus foliaceus, or systemic lupus erythematosus
comprising administering a lymphocytotoxic non-myeloablative amount
of a oxazaphosphorine drug to the subject, such that the subject's
immune system reconstitutes without stem cell transplantation. In
certain embodiments, the oxazaphosphorine drug is cyclophosphamide.
Cyclophosphamide may be administered to the subject at 50 mg/kg for
4 consecutive days. In further embodiments, the method may further
comprise (a) administering to the subject an effective amount of
granulocyte colony stimulating factor; (b) administering to the
subject an effective amount of platelets; and (c) administering to
the subject an effective amount of at least one antimicrobial
agent, such that the immune disorder other than aplastic anemia,
chronic inflammatory demyelinating polyneuropathy, myasthenia
gravis, paraneoplastic pemphigus, pemphigus foliaceus, or systemic
lupus erythematosus is treated in the subject, and/or where the
method does not include both stem cell transplantation and/or
administration of additional immunomodulatory agents.
[0084] In further embodiments, this disclosure relates to a method
of obtaining a cell population substantially free of cells capable
of eliciting an adverse immune reaction in a subject including: (a)
administering a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug to the subject, followed by (b) administering
an effective amount of granulocyte colony stimulating factor to the
subject; (c) administering an effective amount of at least one
antimicrobial agent to the subject; and (d) administering an
effective amount of platelets to the subject, where the method does
not include the use of both stem cell transplantation and
additional immunomodulatory agents.
[0085] In addition to autoimmune diseases, this disclosure also
encompasses the treatment of other adverse immune reactions such as
allergic reactions and transplant rejections. The method comprises
administering (a) a lymphocytotoxic non-myeloablative amount of a
oxazaphosphorine drug to the subject, where the method does not
include the use of both stem cell transplantation and additional
immunomodulatory agents, and wherein the method may further
comprise (b) administering an effective amount of granulocyte
colony stimulating factor to the subject; (c) administering an
effective amount of at least one antimicrobial agent to the
subject; and (d) administering an effective amount of platelets to
the subject.
[0086] In some embodiments, one or more methods described herein
further include the step of identifying a subject with the immune
disorder, which is being treated using a method described
herein.
[0087] In some embodiments, this disclosure relates to the
treatment of scleroderma in a subject comprising administration of
a lymphocytotoxic non-myeloablative amount of a oxazaphosphorine
drug to the subject, thereby to treat scleroderma.
[0088] In some embodiments, this disclosure provides a method of
treating multiple sclerosis in a subject in need thereof
comprising: (a) identifying a subject that failed to respond to
conventional therapy; and (b) administering a lymphocytotoxic
non-myeloablative amount of a oxazaphosphorine drug to the subject,
thereby to treat multiple sclerosis. In some embodiments, this
disclosure provides a method of treating multiple sclerosis in a
subject comprising: (a) identifying a subject having at least two
gadolinium enhancing lesions; and (b) administering a
lymphocytotoxic non-myeloablative amount of a oxazaphosphorine drug
to the subject, thereby to treat multiple sclerosis. In certain
embodiments, the multiple sclerosis is aggressive relapsing
remitting multiple sclerosis. In certain embodiments, the
oxazaphosphorine drug is cyclophosphamide. Cyclophosphamide may be
administered to the subject at 50 mg/kg for 4 consecutive days. In
further embodiments, the method may further comprise (a)
administering to the subject an effective amount of granulocyte
colony stimulating factor; (b) administering to the subject an
effective amount of platelets; and (c) administering to the subject
an effective amount of at least one antimicrobial agent, such that
multiple sclerosis is treated in the subject, and/or where the
method does not include stem cell transplantation and/or
administration of additional immunomodulatory agents.
[0089] In some embodiments, this disclosure provides a method of
treating systemic lupus erythematosus in a subject in need thereof
including: (a) administering to the subject 50 mg/kg of
cyclophosphamide for 4 consecutive days followed by, (b)
administering to the subject an effective amount of granulocyte
colony stimulating factor; (c) administering to the subject an
effective amount of platelets; and (d) administering to the subject
an effective amount of at least one antimicrobial agent, such that
systemic lupus erythematosus is treated in the subject, where the
method does not include both stem cell transplantation and
administration of additional immunomodulatory agents.
[0090] In certain embodiments, this disclosure provides a method of
treating autoimmune hemolytic anemia in a subject in need thereof
comprising: (a) administering to the subject 50 mg/kg of
cyclophosphamide for 4 consecutive days followed by, (b)
administering to the subject an effective amount of granulocyte
colony stimulating factor, such that autoimmune hemolytic anemia is
treated in the subject, where the method does not include both stem
cell transplantation and administration of additional
immunomodulatory agents.
[0091] Also provided is a method of treating autoimmune
thrombocytopenia in a subject in need thereof comprising: (a)
administering to the subject 50 mg/kg of cyclophosphamide for 4
consecutive days followed by, (b) administering to the subject an
effective amount of granulocyte colony stimulating factor; (c)
administering to the subject an effective amount of platelets; and
(d) administering to the subject an effective amount of at least
one antimicrobial agent, such that autoimmune thrombocytopenia is
treated in the subject, where the method does not include both stem
cell transplantation and administration of additional
immunomodulatory agents.
[0092] In some embodiments, this disclosure includes a method of
treating pemphigus vulgaris in a subject in need thereof
comprising: (a) administering to the subject 50 mg/kg of
cyclophosphamide for 4 consecutive days followed by, (b)
administering to the subject an effective amount of granulocyte
colony stimulating factor; (c) administering to the subject an
effective amount of platelets; and (d) administering to the subject
an effective amount of at least one antimicrobial agent, such that
pemphigus vulgaris is treated in the subject, where the method does
not include both stem cell transplantation and administration of
additional immunomodulatory agents.
[0093] Also encompassed by this disclosure is a method of treating
myasthenia gravis in a subject in need thereof comprising: (a)
administering to the subject 50 mg/kg of cyclophosphamide for 4
consecutive days followed by, (b) administering to the subject an
effective amount of granulocyte colony stimulating factor; (c)
administering to the subject an effective amount of platelets; and
(d) administering to the subject an effective amount of at least
one antimicrobial agent, such that myasthenia gravis is treated in
the subject, where the method does not include both stem cell
transplantation and administration of additional immunomodulatory
agents.
EXAMPLES
[0094] The invention having been generally described, may be more
readily understood by reference to the following examples, which
are included merely for purposes of illustration of certain aspects
and embodiments of the present invention, and are not intended to
limit the invention in any way.
Example 1
Use of High Dose Cyclophosphamide for the Treatment of Multiple
Sclerosis
[0095] High-dose cyclophosphamide is used for treating multiple
sclerosis, including aggressive relapsing remitting multiple
sclerosis (MS). MS is an autoimmune disease characterized by
progressive immune-mediated destruction of myelin and axons within
the CNS. At least five conventional therapies are described for the
treatment of MS including, for example, interferon .beta.-1b
(BETASERON), interferon .beta.-1a (AVONEX and REBIF), glatiramer
acetate (COPAXONE) and mitixantrone (NOVANTRONE). High-dose
cyclophosphamide therapy is especially useful for the treatment of
those MS patients that fail to respond to conventional therapy.
Such patients are identified, for example, by the Expanded
Disability Status Scale (EDSS), the MS functional composite (MSFC),
neurocognitive studies and brain parenchymal fraction (BPF).
[0096] Most patients on conventional immunomodulatory therapy
continue to accrue progressive disability. Although immunoablation
strategies with transplantation may be effective in some patients
in halting disease and inducing stable remission, these strategies
are associated with unacceptable mortality rates, precluding the
use of this treatment in most patients. Additionally, long-term
conventional immunomodulatory treatment and immune ablation with
transplantation are exceedingly expensive therapies and may result
in only temporary disease suppression. Patients that do not respond
to a conventional therapy, as identified by one or more of the
foregoing criteria (e.g., having an EDSS from 1.5-6.5), are treated
with high-dose cyclophosphamide (e.g., 50 mg/kg/3-4 days) followed
by administration of GCSF, 6 days after the completion of high-dose
cyclophosphamide treatment, until the neutrophil count exceeds
1.0.times.10.sup.9 per liter. Patients are typically administered
antibiotics until their neutrophil count returns to within the
normal range.
[0097] High-dose cyclophosphamide treatment is also used for
treating patients that have at least one, or at least two
gadolinium enhancing lesions in the brain. Such lesions can be
identified, for example, using MRI and other brain scanning
techniques.
[0098] As described herein, we have also investigated the use and
safety of high-dose cyclophosphamide without transplantation in
patients with aggressive MS. Open-label trial of patients with
aggressive MS were given an up-front regimen of 50 mg/kg/d for four
consecutive days. Enrolled patients had aggressive MS as defined by
2 or more total gadolinium enhancing lesions on each of two
pretreatment MRI scans; at least one clinical exacerbation in the
last year despite being on conventional MS therapy; and sustained
increase of >1.0 on the EDSS in the preceding year.
[0099] Eight patients completed the cyclophosphamide administration
and no patients demonstrated an unexpected grade 3 or 4 adverse
event. All patients developed transient severe neutropenia, an
expected consequence, followed by immune reconstitution in 10-17
days. All patients demonstrated a reduction or elimination of new
and enhancing lesions on the MRI. Brain atrophy has been slowed in
several patients. No patient demonstrated a clinical exacerbation
following treatment and most patients showed a reduction in EDSS
and an improvement in the MSFC following treatment. We also
analyzed changes in microglial activation after HiCy using
[.sup.11C]-R-PK11195-PET imaging.
[0100] High-dose cyclophosphamide treatment is safer and more
effective than using immunoablation with stem cell transplantation
for treating MS, including aggressive MS.
Example 2
High-Dose Cyclophosphamide Treatment of Severe Aplastic Anemia
[0101] Acquired severe aplastic anemia (SAA) is a rare
hematopoietic disorder characterized by pancytopenia and a
hypocellular bone marrow. With supportive care alone, most patients
die of the disease within a year of diagnosis. The majority of
acquired SAA results from autoimmune destruction of bone marrow
cells. Like other autoimmune diseases damage to the target organ
(i.e., the bone marrow) is felt to be mediated by cytotoxic
T-lymphocytes, which are demonstrable in the blood and marrow.
[0102] The pathophysiology of aplastic anemia has led to two main
approaches to therapy: replacement of both the immune system and
deficient hematopoietic stem cells by allogeneic SCT (in patients
with a suitable donor) or suppression of the destructive
immunologic process with anti-thymocyte globulin and cyclosporine
(ATG/CSA). Allogeneic SCT from an HLA identical sibling has the
potential to cure SAA. In patients under the age of 25 the cure
rate is 80-90%; however, in patients older than 40 years, the cure
rate is roughly 50%. For patients with no HLA identical sibling
ATG/CSA is commonly employed. ATG/CSA leads to improved hemopoiesis
in 60-80% of patients, but does not often result in cure. Most
patients relapse, become dependent on long-term immunosuppression
or acquire a secondary clonal disease, such as paroxysmal nocturnal
hemoglobinuria (PNH) or myelodysplastic syndromes (MDS).
[0103] In a study of 10 SAA patients treated with high-dose
cyclophosphamide, complete remission (normocellular bone marrow,
hemoglobin >13.0 g/dl, neutrophil count >1.5.times.10.sup.9/L
and a platelet count greater than 125.times.10.sup.9/L) was
achieved in seven of ten patients. In a further study, an
additional 19 previously untreated SAA patients (median age, 47
years) were treated with high-dose cyclophosphamide. The
probability of survival was 84% (95% CI, 59-95%) at 24 months. The
probability of achieving treatment-free remission was 73% (95% CI,
51-91%). No responding patients have had relapse or have developed
secondary clonal disorders. The median time to a neutrophil count
of 500 .mu.L was 49 days.
[0104] Further, we treated 38 previously untreated, and 17
immunosuppressive therapy failed, SAA patients with high-dose
cyclophosphamide (50 mg/kg/d.times.4) followed by daily GCSF (5
ug/kg/day) until the neutrophil count (ANC) reached 1000/d1.
Response was defined as ANC >1000/d1 and transfusion
independence without growth factor support for >3 months.
Relapse was defined as no longer meeting criteria for response.
Development of paroxysmal nocturnal hemoglobinuria was monitored by
flow cytometry.
[0105] The median age of the newly diagnosed patients was 40 (range
2-68) years. With a median follow-up of 41 (range, 6-111) months,
33/38 patients survive (actuarial survival of 86%, 95% CI 72-95%)
with 28 (74%, 95% CI 58-85%) achieving remission, most being
complete. Median time to ANC of 500, last platelet and red cell
transfusion was 50, 99, and 181 days, respectively. Before
treatment, 15 patients met criteria for very (v) SAA (ANC <200).
Mortality within 6 months after high-dose cyclophosphamide
treatment occurred in 4 (10.5%) patients, all with vSAA; 1
additional patient died from bacterial sepsis 18 months after
high-dose cyclophosphamide treatment 22/23 (96%) SAA patients
survive (20 in remission) compared to 11/15 (73%) with vSAA (10 in
remission). Eight patients had a severe infection at the time of
beginning treatment and 5 survive in remission. PNH screening
revealed a PNH population ranging from 0.5-40% of granulocytes in
12 patients, and all 12 achieved a durable remission (p=0.039). No
patient in this series has progressed to PNH or MDS, and the PNH
clone is regressing in all 12 patients. Two patients have relapsed.
One patient, whose first remission lasted 5 years, was retreated
with high-dose cyclophosphamide into a persisting second complete
remission 3 years ago; another patient recently relapsed 3 years
after achieving remission. Ten of the 17 patients who failed
immunosuppressive therapy (median age of 31, range 6-58) are alive
and nine are in remission.
[0106] High-dose cyclophosphamide is a safe and highly effective
therapy for both untreated and relapsed SAA. Relapses after
high-dose cyclophosphamide are rare and progression to paroxysmal
nocturnal hemoglobinuria or myelodysplastic syndromes in previously
untreated patients has not been observed in this series with now 15
patients out beyond 5 years. The presence of a paroxysmal nocturnal
hemoglobinuria population may be a favorable risk factor, perhaps
by excluding non-immune mediated forms of SAA.
Example 3
Treatment of Hepatitis-Associated Aplastic Anemia with High Dose
Cyclophosphamide
[0107] Hepatitis-associated aplastic anemia (HAA) is a rare variant
of aplastic anemia that accounts for 5% of cases. The hepatitis is
seronegative and most often spontaneously resolves. The aplastic
anemia that follows presents within a few months after the onset of
hepatitis and is often fatal. One study that investigated the
treatment for HAA used antithymocyte globulin and cyclosporine,
which induced remissions in 7 of 10 patients, with up to one year
of follow-up. In that study, there were 3 deaths related to
treatment failure and 1 relapse. High-dose cyclosphosphamide
induces durable remissions in severe aplastic anemia (SAA) and
other autoimmune diseases, and we hypothesized that it could induce
durable remissions in HAA as well.
[0108] Five patients (ages 6-17 years) with HAA and without a
matched sibling BMT option were treated with cyclophosphamide (50
mg/kg/day IV.times.4 days) plus mesna. Serology/PCR for HAV, HBV,
HCV, EBV, and CMV were negative. All patients met criteria for very
severe aplastic anemia pretreatment: bone marrow cellularity
<25%, ANC <200 .mu.L, platelet count <20,000/.mu.L,
absolute reticulocyte count <60,000/.mu.L. Infection prophylaxis
consisted of trimethoprim/sulfamethoxazole, G-CSF, and
fluconazole.
[0109] All patients were transfusion dependent for erythrocytes and
platelets prior to high dose cyclophosphamide. Other baseline and
current values are shown in Table I. Four patients demonstrated
hematopoietic recovery. Median time to ANC >500/.mu.L was 51
days (range 44-369). Median time to transfusion independence for
erythrocytes and platelets was 109 (range 57-679) and 160 (range
48-679) days, respectively. The 4 patients with hematopoietic
responses are in remission up to 6 years after treatment without
further immune suppression beyond high-dose cyclophosphamide.
Patient 2 met criteria for autoimmune hepatitis (AIH), and her AIH
remains in remission, as well. Patient 5 had no hematopoietic
response and died 3 months after BMT of multi-organ failure.
[0110] High-dose cyclophosphamide induced durable remissions in
hepatitis-associated aplastic anemia in 4 of 5 patients based on
follow-up from 1-6 years. Treatment failure led to one death in
this series. The remission of HAA and AIH in one patient suggests
that high dose CY may be an alternative and effective treatment for
AIH, which is a disease characterized by long-term dependence on
immunosuppression and recurrentrelapses.
TABLE-US-00001 TABLE I Pre-Treatment and Current Patient
Characteristics ANC (cells/.mu.L) ALT (U/L) Hgb (g/dL) Platelets
(1000/.mu.L) Age/Sex Follow Up Nadir/Current Peak/Current Current
Current 17/F 6 y 138/3430 1832/16 11.1 99 9/F* 2 y 178/2500 1186/11
13 140 14/M 16 mo 0/2380 2800/31 13.7 98 6/F 13 mo 0/669 2213/21
13.9 37 16/F 5 mo.dagger. 0/.dagger. 3051/.dagger. .dagger.
.dagger. *ANA titer >1:640 and anti-smooth muscle Ab titer 1:40.
.dagger.Had no hematologic response and proceeded to unrelated BMT
after 5 months.
Example 4
High-Dose Cyclophosphamide Treatment for Other Refractory
Autoimmune Disorders
[0111] To investigate the treatment of other autoimmune and
possibly alloimmune conditions using high-dose cyclophosphamide,
eight patients suffering from a variety of severe refractory
autoimmune disorders (2 systemic lupus erythematosus, 2 Felty
syndrome, 1 immune thrombocytopenia, 2 autoimmune hemolytic anemia,
and 1 chronic inflammatory demyelinating polyneuropathy) were
treated with high-dose cyclophosphamide. Seven patients showed
marked clinical improvement: five achieved a complete remission and
2 achieved a partial remission. Hematopoietic reconstitution was
rapid. The median time to a neutrophil count of 500 per .mu.L and
platelet transfusion independence was 17 and 16 days after the last
dose of cyclophosphamide, respectively.
[0112] In a further study, 14 patients with moderate to severe
systemic lupus erythematosus (SLE) that was refractory to
corticosteroids and one or more additional immunosuppressive
regimen were treated with high-dose cyclophosphamide. In this
group, the median time to a neutrophil count of 500 .mu.l was 14
days (range, 11 to 22 days) after the last dose of cyclophophamide.
Patients required a median of 2 transfusions (range, 2 to 5) of
packed red blood cells and the median day to last platelet
transfusion was day 16 (range, 0 to 23). There were no deaths or
fungal infections. A significant improvement in Physicians Global
Assessment (mean difference 1.3, p<0.0001), systemic lupus
erythematosus disease activity index (mean difference 3.5 p=0.042)
and prednisone dosage (mean difference 12.8 mg, p=0.01) was
observed. Responses, including 5 durable complete responses, were
observed in all organ systems, renal, central nervous system and
skin that led to patient enrollment.
[0113] High-dose cyclophosphamide also induces durable complete
remissions in patients with paraneoplastic pemphigus and pemphigus
vulgaris. Following high-dose cyclophosphamide treatment, a patient
with paraneoplastic pemphigus did not require blood products and
recovered to a neutrophil count of greater than 500 per .mu.L by
day 15. The patient with pemphigus vulgaris began to recover
neutrophils by day 9; he received 2 platelet transfusions, but did
not require red cell transfusions. In both patients, the pathogenic
autoantibodies specific for the disease became undetectable after
high-dose cyclophosphamide treatment.
[0114] Durable remission following high-dose cyclophosphamide was
also observed in refractory autoimmune hemolytic anemia. For
example, 9 patients suffering from refractory autoimmune hemolytic
anemia were treated with high-dose cyclophosphamide; 7 had an IgG
warm autoantibody, one had an IgM cold agglutinin and one had both
warm and cold agglutinin disease. The median hemoglobin at the time
of treatment was 6.7 (range; 5-10) g/dl and 8 of the 9 patients
were dependent on erythrocyte transfusions. The median times to a
neutrophil count of 500 per .mu.L and to platelet transfusion
independence after high-dose cyclophosphamide treatment was 16 and
15 days, respectively. All patients responded and became
transfusion independent; 6 patients achieved a complete remission
(normal untransfused hemoglobin for age and sex) and 3 patients
achieved a partial remission (hemoglobin >10.0 g/dl without
support of transfusions). There were no relapses at a median
follow-up of 15 (range; 4-29) months and 7 of the 9 patients were
able to discontinue steroids.
[0115] High-dose cyclophosphamide may also be used to eradicate
alloimmunization, a major problem in patients who require chronic
blood transfusions and in patients being considered for organ
transplantation. Five patients with SAA who were refractory to
platelet transfusions due to HLA-specific antibodies were studied
before and after treatment with high-dose cyclophosphamide.
Complete remission of the SAA was achieved in four of these five
patients. All four responders demonstrated a marked reduction in
anti-HLA antibody titer after high-dose cyclophosphamide; in three
of these patients the antibody was completely eradicated suggesting
that high-dose cyclophosphamide may have the potential to treat
alloimmune conditions.
[0116] In a further study, we treated 7 patients with myasthenia
gravis refractory to extensive conventional immunosuppressive
therapy, using high-dose cyclophosphamide. All of these patients
markedly improved, and returned to full activity.
[0117] The specification is most thoroughly understood in light of
the teachings of the references cited within the specification,
which are hereby incorporated by reference. The embodiments within
the specification provide an illustration of embodiments in this
disclosure and should not be construed to limit its scope. The
skilled artisan readily recognizes that many other embodiments are
encompassed by this disclosure. All publications and patents cited
and sequences identified by accession or database reference numbers
in this disclosure are incorporated by reference in their entirety.
To the extent that the material incorporated by reference
contradicts or is inconsistent with the present specification, the
present specification will supercede any such material. The
citation of any references herein is not an admission that such
references are prior art to the present disclosure.
[0118] Unless otherwise indicated, all numbers expressing
quantities of ingredients, cell culture, treatment conditions, and
so forth used in the specification, including claims, are to be
understood as being modified in all instances by the term "about."
Accordingly, unless otherwise indicated to the contrary, the
numerical parameters are approximations and may vary depending upon
the desired properties sought to be obtained by the present
invention. Unless otherwise indicated, the term "at least"
preceding a series of elements is to be understood to refer to
every element in the series. Those skilled in the art will
recognize, or be able to ascertain using no more than routine
experimentation, many equivalents to the specific embodiments of
the invention described herein. Such equivalents are intended to be
encompassed by the following claims.
* * * * *